Gunshot wounds

uring the period from October 2 to October 22, 2002, ten people were killed and two additional people were wounded in a series of sniper attacks that spanned Maryland, Virginia, and the District of Columbia and stirred terror throughout the region. These acts of terrorism were inspired not by a political ideology but by a desire to create fear in the community and then extort money from local government. Because of the random targeting of victims, individuals in the community had limited ability to predict their own risk. The shootings occurred in multiple public settings. A teenage boy was shot as he prepared to enter his middle school. A bus driver was shot in the doorway of his bus. Other shootings occurred at gas stations, shopping malls, and a restaurant. The shootings occurred during daytime and evening hours. The victims had no common characteristics. Few clues were available to law enforcement officials. Two suspects were finally apprehended on 24 October, 2002. The shootings drew widespread media coverage. School systems curtailed outdoor recess and after-school activities, and sports clubs postponed competitive events. Communities developed indoor alternatives to usual Halloween activities in anticipation that the shootings would continue through the end of the month.

Objectives To describe the use of radiology in the emergency department (ED) in a trauma centre during a mass casualty incident, using a minimum acceptable care (MAC) strategy in which CT was restricted to potentially severe head injuries. Methods We retrospectively studied the initial use of imaging on patients triaged to the trauma centre following the twin terrorist attacks in Norway on 22 July 2011. Results Nine patients from the explosion and 15 from the shooting were included. Fourteen patients had an Injury Severity Score >15. During the first 15 h, 22/24 patients underwent imaging in the ED. All 15 gunshot patients had plain films taken in the ED, compared to three from the explosion. A CT was performed in 18/24 patients; ten of these were completed in the ED and included five non-head CTs, the latter representing deviations from the MAC strategy. No CT referrals were delayed or declined. Mobilisation of radiology personnel resulted in a tripling of the staff. Conclusions Plain film and CT capacity was never exceeded despite deviations from the MAC strategy. An updated disaster management plan will require the radiologist to cancel non-head CTs performed in the ED until no additional MCI patients are expected. Key points • Minimum acceptable care (MAC) should replace normal routines in mass casualty incidents. • MAC implied reduced use of imaging in the emergency department (ED). • CT in ED was restricted to suspected severe head injuries during MAC. • The radiologist should cancel all non-head CTs in the ED during MAC.

To describe the use of radiology in the emergency department (ED) in a trauma centre during a mass casualty incident, using a minimum acceptable care (MAC) strategy in which CT was restricted to potentially severe head injuries. We retrospectively studied the initial use of imaging on patients triaged to the trauma centre following the twin terrorist attacks in Norway on 22 July 2011. Nine patients from the explosion and 15 from the shooting were included. Fourteen patients had an Injury Severity Score >15. During the first 15 h, 22/24 patients underwent imaging in the ED. All 15 gunshot patients had plain films taken in the ED, compared to three from the explosion. A CT was performed in 18/24 patients; ten of these were completed in the ED and included five non-head CTs, the latter representing deviations from the MAC strategy. No CT referrals were delayed or declined. Mobilisation of radiology personnel resulted in a tripling of the staff. Plain film and CT capacity was never e...

A 26-year-old soldier from Peru was shot in the right upper back of the abdomen while on routine patrol in a drug-traffic region in the Peruvian highlands. After temporizing exploratory laparotomy in a mobile army surgical hospital, he was flown to a referral center (Trauma-Shock Unit, Central Military Hospital, Lima, Peru) for open surgery. Surgical diagnosis was open abdominal trauma compromising the right kidney, ascending bowel, and a 2-cm duodenal perforation. During cleaning, debriding, and repair of the duodenal perforation (after right nephrectomy and hemicolectomy), a cylindric parasite resembling a large earthworm emerged from the small intestinal wound and swam into the surrounding peritoneal cavity ( Figure and Figure ). The parasite was confirmed to be an adult female Ascaris lumbricoides. The patient received antibiotic therapy and 400 mg of albendazole when able to take oral fluids. The patient did well after surgery and was later discharged in good condition. Ascaris lumbricoides is a geohelminth commonly found to infect humans in the developing world. 1 Adult worms inhabit the small intestine where, if present in large numbers, they can obstruct the intestinal lumen, or actively migrate through the biliary or pancreatic ducts. Although atypical, finding of adult Ascaris during intestinal trauma surgery 2 may not be surprising.

EXECUTIVE SUMMARYFirearm-related injury and death continue to be a significant problem in Canada. Since the 1990s Canadian emergency physicians (EPs) have played an active role in advocating for gun control. This paper updates the Canadian Association of Emergency Physician's (CAEP's) position on gun control. Despite a media focus on homicide, the majority of firearm-related deaths are a result of suicide. Less than 40% of firearm-related injuries are intentionally inflicted by another person. Since the implementation of Canada's gun registry in 1995, there has been a significant reduction in firearm-related suicides and intimate partner homicides. Proposed weakening of gun laws in Canada will have a significant impact on firearm-related mortality and injury. There must be instead an expansion of programs focused on prevention of suicide, intimate partner violence and gang-related violence.The majority of intentional or unintentional firearm-related injuries involve a vi...

There are more than seven million firearms in Canada and approximately 1400 firearm-related deaths per year. These figures are far greater than those for most European countries, but far less than those for the United States. This article will discuss the different classes of firearm deaths and the associated costs. Public health issues will be explored, especially as they relate to the involvement of the Canadian Association of Emergency Physicians, as well as injury control recommendations.

Study design: Review article. Objectives: To review the literature regarding treatment approaches in cases of gunshot wounds (GSWs) affecting the spine. Setting: Brazil. Methods: Narrative review of medical literature. Results: GSWs are an increasing cause of morbidity and mortality. Most patients with spinal GSW have complete neurological deficit. The injury is more common in young men and is frequently immobilizing. The initial approach should follow advanced trauma life support, and broad-spectrum antibiotic therapy should be initiated immediately, especially in patients with perforation of the gastrointestinal tract. The indications for surgery in spinal GSW are deterioration of the neurologic condition in a patient with incomplete neurological deficit, the presence of liquor fistula, spinal instability, intoxication by the metal from the bullet or risk of bullet migration. Conclusion: Surgical treatment is associated with a higher complication rate than conservative treatment. Therefore, the surgeon must know the treatment limitations and recognize patients who would truly benefit from surgery.

Letters to the Editor Table 1 Number ofpatients according to the speciality of the referring consultanit, type of 7neurological disorder diagnosed, and number ofpatients whose diagnzosis was changed by neurologists Specialty of the rNfening consultant General medicine Medical subspecialties Cardiac Renal Liver Respiratory HIV/AIDS General surgery

Gunshot wounds require surgeons to decide whether to remove or leave bullet fragments in the body. Surgeons also decide how to follow up with patients who have lead fragments retained in their body. Current literature recommends to remove only intra-articular fragments without the need for a follow-up for patients with the metal retained. Therefore, this study investigates chronic lead toxicity for gunshot wounds. The study was performed in the metropolitan area of Rio de Janeiro/Brazil, between 2013 and 2015. It was a case-control study that included 45 victims of gunshot lesions with metallic fragments retained for more than 6 months. The 45 controls were matched for gender, age, and race. We compared the lead blood levels and frequency of symptoms.

Arteriovenöz malformasyonlar(AVM) yüksek akımlı arteriovenöz şantlara eşlik eden venöz göllenmeler ile birliktelik gösterebilir. Bu vasküler kitleler deri lezyonları yanı sıra vital organlara bası yaparak fonsiyonel yetersizlikler de oluşturabilir. Endovasküler selektif arteriyel embolizasyona (onyx® likid embolik sistem) ek olarak venöz göllenmelere perkütanöz obliteran madde (%20 n-butil siyanoakrilat) enjeksiyonu kombinasyonu ile fonksyonel ve estetik iyileşme elde edilen vaka sunulmuştur. Abstract Arteriovenous malformations (AVM) can be seen together with high flow arteriovenous shunts that are accompanying with venous lakes. These vascular masses can give rise to functional insufficiency by pressing the vital organs. In addition to endovascular selective arterial embolization (onyx® likid embolic system) in this case we used obliterating material combination for the improvement of the venous lakes. In this way we achieved functional and esthetic improvement.

The lynx, which was reintroduced to Switzerland after being exterminated at the beginning of the 20th century, is protected by Swiss law. However, poaching occurs from time to time, which makes criminal investigations necessary. In the presented case, an illegally shot lynx was examined by conventional plane radiography and three-dimensional multislice computertomography (3D MSCT), of which the latter yielded superior results with respect to documentation and reconstruction of the inflicted gunshot wounds.We believe that 3D MSCT, already described in human forensic-pathological cases, is also a suitable and promising new technique for veterinary pathology.

We report a case of an accidental death or potential suicide by revolver with subsequent injury of another person. A 44-year-old man shot himself in the head while manipulating his .38 caliber special revolver in the kitchen in the presence of his wife, standing approximately 1.5 m next to him. After passing through the husband's head, the lead round-nose bullet entered the region underneath his wife's left eye. When the bullet left the man's head, it retained the energy to penetrate the soft tissue at this distance, including the skin and thin bone plates like the orbital wall. Owing to the low energy of the projectile, the entry wound was of atypical in shape and without loss of tissue. Only a small lineV resembling a cutVwas externally visible. The man died in the hospital from his injuries; his wife suffered visual loss of her left eye.

Kinetic energy non-lethal projectiles are used to impart sufficient effect onto a person in order to deter uncivil or hazardous behavior with a low probability of permanent injury. Since their first use, real cases indicate that the injuries inflicted by such projectiles may be irreversible and sometimes lead to death, especially for the head impacts. Given the high velocities and the low masses involved in such impacts, the assessment approaches proposed in automotive crash tests and sports may not be appropriate. Therefore, there is a need of a specific approach to assess the lethality of these projectiles. In this framework, some recent research data referred in this article as "force wall approach" suggest the use of three lesional thresholds (unconsciousness, meningeal damages and bone damages) that depend on the intracranial pressure. Three corresponding critical impact forces are determined for a reference projectile. Based on the principle that equal rigid wall max...

The recent Afghanistan conflict caused a higher proportion of casualties with facial injuries due to both the increasing effectiveness of combat body armour and the insurgent use of the improvised explosive device (IED). The aim of this study was to describe all injuries to the face sustained by UK service personnel from blast or gunshot wounds during the highest intensity period of combat operations in Afghanistan. Methods: Hospital records and Joint Theatre Trauma Registry data were collected for all UK service personnel killed or wounded by blast and gunshot wounds in Afghanistan between 01 April 2006 and 01 March 2013. Results: 566 casualties were identified, 504 from blast and 52 from gunshot injuries. 75% of blast injury casualties survived and the IED was the most common mechanism of injury with the mid-face the most commonly affected facial region. In blast injuries a facial fracture was a significant marker for increased total injury severity score. A facial gunshot wound was fatal in 53% of cases. The majority of survivors required a single surgical procedure for the facial injury but further reconstruction was required in 156 of the 375 of survivors aero medically evacuated to the UK. Conclusions: The presence and pattern of facial fractures was significantly different in survivors and fatalities, which may reflect the power of the blast that these cohorts were exposed to. The Anatomical Injury Scoring of the Injury Severity Scale was inadequate for determining the extent of soft tissue facial injuries and did not predict morbidity of the injury. 2016 Published by Elsevier Ltd.

ObjectiveTo retrospectively investigate the experience at one urban level one trauma center with gunshot femoral fractures with vascular injury and to examine the implication of surgical sequence with regards to short‐term complications and ischaemia time.MethodsWe performed a retrospective study of 24 patients treated at an urban level one trauma center over a 10‐year period with low velocity gunshot wounds resulting in femur fractures and major vascular injury. Data were stratified according to sequence of surgical intervention.ResultsThe mean age was 31.3 years. Mean time to revascularization was highest in patients undergoing definitive orthopaedic fixation first (660 min) and lowest in patient undergoing shunting first (210 min). Most complications in patients undergoing vascular repair first, included two disrupted repairs requiring immediate revision after subsequent orthopaedic fixation. Other complications included compartment syndrome and one amputation.ConclusionSurgical ...

Background: Low-velocity pelvic gunshot injuries occur commonly in urban trauma centers, occasionally involving concomitant intestinal viscus injury leading to potential fracture site contamination. Surgical debridement of the fractures may be necessary to prevent osteomyelitis, although not routinely performed in many centers. The purpose of this study was to determine whether fracture debridement should be done to prevent osteomyelitis in these injuries. Methods: A 5-year retrospective review of all patients older than 12 years with low-velocity gunshot pelvic fractures was performed at an urban Level I trauma center. Medical records and radiographs/computed tomographic scans were reviewed, and data regarding fracture location, concomitant intestinal viscus injury, orthopedic surgical intervention, antibiotic treatment, and bone and/or joint infection were recorded. Results: Of a total of 103 patients identified, 19 had expired within 48 hours and were excluded, resulting in a total of 84 study subjects for review. Fifty of 84 patients (59%) had a perforated viscus with 31 large bowel injuries and 30 small bowel injuries. Eighteen patients (21%) had intra-articular fractures, 15 of which involved the hip joint. Orthopedic surgical fracture debridement was done only in intra-articular fractures with retained bullet fragments (seven cases). Deep infection occurred in one patient with a missile injury to the hip joint with concomitant intestinal spillage. Immediate joint debridement was performed in this case, but successful missile fragment removal was not achieved until the second debridement after 48 hours. No infections occurred in any extra-articular fractures, regardless of the presence of intestinal spillage. Conclusions: Extra-articular gunshot pelvic fractures do not require formal orthopedic fracture debridement even in cases with concomitant intestinal viscus injury. However, debridement with bullet removal should be done in cases with intra-articular involvement, particularly if there are retained bullet fragments in the joint, to prevent deep infection.

• Multiple correspondence is used to examine patterns of gunshot and blast-related fractures. • Cranial fractures are associated with gunshot related deaths. • Post-cranial fractures are associated with blast-related deaths. • Distinction between cranial and post-cranial trauma can be used in cases of suspected blast trauma in anthropological assemblages.

Endovascular techniques have shown to be useful in the management of vascular injuries because they transform a complex and potentially dangerous procedure into a safe one. We present the case of a 39-year-old man with congestive heart failure and abdominal bruit 11 years after an abdominal gunshot wound. Imaging studies revealed an arteriovenous fistula involving the left iliac artery bifurcation, and an iliac branch device was used to treat it. Symptoms resolved, and follow-up imaging showed patency of the graft and closure of the arteriovenous communication. To our knowledge, this is the first report of a nonaneurysmal disease treated with this device. (

Despite the recent advances in the post-mortem forensic examinations, some medico-legal institutes are limited in accessing improved technological facilities, hampering an optimal autopsy. Specifically in developing countries, high-cost imaging devices are not afforded, making necessary the development of alternative autopsy techniques. In parallel, in dental autopsies muscle stiffness is often observed lacking mouth opening. This situation is specifically worse in cases of intraoral firearm injuries, in which detailed description of the detected wounds must be reported post-mortem. Based on this context, the present study aims to illustrate two cases of intraoral firearm injuries, in which the dental autopsies were performed considering a conservative and alternative technique for the improvement of mouth opening. Both cases provided optimal results, indicating the new approach as a valuable tool for dental autopsies.

September 2005, Vol. 95, No. 9 SAMJ A 27-year-old man presented to the trauma unit of a regional hospital after sustaining a single gunshot wound to the head. Although the exact range and calibre were unknown, the patient confirmed seeing the assailant use a handgun. A brief period of depressed consciousness following the injury was reported. However, on presentation the patient was alert with a Glasgow Coma Score of 15/15. No seizures were reported. On examination, a right parietal bone entrance wound was noted, with no obvious exit wound. No cerebrospinal fluid otorrhoea or rhinorrhoea was noted. The patient also had a left hemiparesis and left upper motor neuron facial nerve palsy. No other abnormalities were noted. A computed tomography (CT) scan was performed (Figs. 1(a) and (b)).

Understanding global variation in firearm mortality rates could guide prevention policies and interventions. To estimate mortality due to firearm injury deaths from 1990 to 2016 in 195 countries and territories. This study used deidentified aggregated data including 13 812 location-years of vital registration data to generate estimates of levels and rates of death by age-sex-year-location. The proportion of suicides in which a firearm was the lethal means was combined with an estimate of per capita gun ownership in a revised proxy measure used to evaluate the relationship between availability or access to firearms and firearm injury deaths. Firearm ownership and access. Cause-specific deaths by age, sex, location, and year. Worldwide, it was estimated that 251 000 (95% uncertainty interval [UI], 195 000-276 000) people died from firearm injuries in 2016, with 6 countries (Brazil, United States, Mexico, Colombia, Venezuela, and Guatemala) accounting for 50.5% (95% UI, 42.2%-54.8%) of...

Several factors have been considered important for the decision between diversion and primary repair in the surgical management of colorectal injuries. The aim of this study is to clarify whether patients with colorectal injuries need diversion or not.

Comment: As CT utilization rates have increased for the diagnosis of appendicitis in children, so have concerns for radiation exposure. This paper demonstrates that a diagnostic algorithm for appendicitis decreases CT utilization and maintains good diagnostic and pragmatic value. Furthermore, it highlights the feasibility and significant value of a multidisciplinary approach to a quality improvement project including surgery, radiology, and emergency medicine. The authors described some issues with adherence (in approximately 50% of patients, the algorithm was not followed despite concerted efforts to remind and educate staff about it), but interestingly in those patients CT utilization also decreased, showing perhaps that just exposure or knowledge of the algorithm had an effect on clinical practice.

W hile dural venous sinus thrombosis is a wellrecognized cause of elevated intracranial pressure (ICP), little attention has been given to nonthrombotic causes of occlusion to venous sinuses. Furthermore, depressed skull fractures occur over venous sinuses in 11%-18% of cases, representing a fairly large proportion of these cases. 16,19 Nonetheless, very few cases of intracranial hypertension due to venous sinus compression have been reported. 12 Traditionally, conservative management of depressed skull fractures that lie over venous sinuses has been preferred over surgical treatment because of the risk of hemorrhage associated with operating over a venous sinus. 16,19 However, in cases in which neurological deficits are present with elevated ICP, surgical treatment is preferred. 8,14,15 In this article, we describe the case of a 25-year-old woman who presented with a 3-week history of worsening headache, blurry vision, and diplopia following removal of bullet fragments from a gunshot wound (GSW) to the head. We report on the successful surgical management of a depressed skull fracture compromising flow through the superior sagittal sinus (SSS). case report History and Examination This 25-year-old woman presented with progressive headaches, visual field loss, transient visual obscurations, pulsatile tinnitus, and horizontal double vision developing in the weeks following removal of bullet fragments after a GSW to the posterior head. Urgent ophthalmologi-abbreviatioNs GSW = gunshot wound; ICP = intracranial pressure; Q-MRA = quantitative MR angiography; Q-MRV = quantitative MR venography; SSS = superior sagittal sinus.

Air guns (AGs) use air or another compressed gas to propel a projectile. Different injuries may occur in children due to their body structure, which is less-resistant with thin soft tissue coverage that can be easily penetrated by an AG shot. We present 3 cases of pediatric AG shot injury. The first-case had right lumber deep tissue penetration of AG pallet without internal damage, the second-case had a complex course of pellet into the perineum, and the third-case was shot in the left shoulder. All cases were accidentally shot. The shooters were all children, and relatives of the victims. All patients were generally stable on arrival. Two cases were operated, and one received conservative management. On follow up, no complications were noted.  At first sight, AGs and air rifles may appear relatively harmless, but they are potentially lethal and children should not be allowed to play with them. 

The absence of guns from children' s homes and communities is the most reliable and effective measure to prevent firearm-related injuries in children and adolescents. Adolescent suicide risk is strongly associated with firearm availability. Safe gun storage (guns unloaded and locked, ammunition locked separately) reduces children' s risk of injury. Physician counseling of parents about firearm safety appears to be effective, but firearm safety education programs directed at children are ineffective. The American Academy of Pediatrics continues to support a number of specific measures to reduce the destructive effects of guns in the lives of children and adolescents, including the regulation of the manufacture, sale, purchase, ownership, and use of firearms; a ban on semiautomatic assault weapons; and the strongest possible regulations of handguns for civilian use. SCOPE OF THE PROBLEM Although rates have declined since the American Academy of Pediatrics (AAP) issued the original policy statement in 1992, firearm-related deaths continue as 1 of the top 3 causes of death in American youth. 1 As shown in Fig 1, the firearm-associated death rate among youth ages 15 to 19 has fallen from its peak of 27.8 deaths per 100 000 in 1994 to 11.4 per 100 000 in 2009, driven by a decline in firearm homicide rates. 1 No single study has adequately explained the decline in firearmrelated homicide rates. Postulated reasons include improved socioeconomic conditions, violence prevention programs, decline in the crack/cocaine market, changes in legislation, declines in firearms availability for other reasons, and community policing. Nevertheless, firearm-associated death and disability rates remain unacceptably high. Of all injury deaths of individuals 15 through 19 years of age in the United States in 2009, more than 1 (28.7%) in 4 were firearm related, and of those younger than 20 years, nearly 1 (19.5%) in 5 were firearm related. 1 These firearm deaths result from homicide, suicide, and unintentional injury (Fig 2). Black Americans are particularly affected; injuries from firearms were the leading cause of death among black males 15 through 34 years of age in 2009. 2 Although national data cannot fully document urban and rural differences in the patterns of injuries from firearms that involve children, local data indicate that children in rural areas as well as in urban areas are at risk for firearm-related mortality. 3-5

The phenomenon of bullet embolization has been documented in various organs or major organ systems. A case report of a gunshot wound injury to the left hemithorax with penetration of the esophagus and embolization to the stomach is presented. Diagnostic evaluation and therapy are discussed.

The phenomenon of bullet embolization has been documented in various organs or major organ systems. A case report of a gunshot wound injury to the left hemithorax with penetration of the esophagus and embolization to the stomach is presented. Diagnostic evaluation and therapy are discussed.